Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up
- Study type
- Clinical guideline
- Study name
- ESMO Localised Colon Cancer 2020
- Design
- Clinical guideline of the European Society for Medical Oncology (ESMO) with levels of evidence (I to V) and grades of recommendation (A to E)
- Source
- Ann Oncol · 2020
In plain words
This guideline from the European Society for Medical Oncology (ESMO) explains the treatment pathway for non-metastatic colon cancer: diagnosis by complete colonoscopy, surgery, and a decision on additional chemotherapy based on the tumour stage, the number of lymph nodes and the MSI/MMR test. For many stage 3 patients, 3 months of chemotherapy with CAPOX is enough, and for some low-risk stage 2 patients, follow-up alone is needed. Before starting drugs of the fluorouracil/capecitabine family, a test for DPD enzyme deficiency is recommended to prevent dangerous side effects.
Key guideline recommendations
- I, A
In the absence of an indication for emergency surgery, complete colonoscopy is recommended to confirm the diagnosis of colon cancer and exclude synchronous tumours. If complete colonoscopy is not possible, a limited left-sided colonoscopy combined with CT colonography is an alternative.
- III, A
The risk of recurrence after resection of colon cancer should be assessed by integrating TNM stage, MMR/MSI status and the number of lymph nodes sampled (fewer or more than 12).
- IV, A
MSI/MMR status is the only validated molecular marker in adjuvant treatment decisions and should be determined in stage 2 colorectal cancer. In stage 3, the use of MMR status is limited to identifying Lynch syndrome.
- III, A
DPD genotyping or phenotyping before starting fluoropyrimidine-based adjuvant treatment, as recommended by regulatory agencies, is strongly recommended.
- I, A; ESMO-MCBS v1.1: B
The combination of fluoropyrimidines (5-FU or capecitabine) with oxaliplatin is the backbone of adjuvant treatment for stage 3 colon cancer.
- I, A
The duration of oxaliplatin-based adjuvant treatment in stage 3 colon cancer, based on the IDEA data, can be set at 3 or 6 months for CAPOX [I, A] or 6 months for FOLFOX [I, A], taking into account pathological risk features, comorbidities and the patient's risk assessment.
- I, A / I, B / I, C
For low-risk stage 2 patients, follow-up is recommended [I, A]. For intermediate-risk patients (without MMR/MSI and with any risk factor other than pT4 or fewer than 12 lymph nodes examined), 6 months of fluoropyrimidine is recommended [I, B]. High-risk stage 2 patients (pT4 or fewer than 12 lymph nodes or several intermediate risk factors, regardless of MSI) may be considered for the addition of oxaliplatin [I, C].
- I, A
It is important that adjuvant chemotherapy starts as soon as possible after surgery, preferably within 8 weeks at most.
Study population
Patients with localised (non-metastatic) colon cancer: screening, diagnosis, staging, surgery, adjuvant treatment of stages 2 and 3 and follow-up.
Clinical significance and place in guidelines
At the time of writing, this guideline is the latest full version of the ESMO guideline for localised colon cancer. In January 2026, ESMO published an Express Update on structured exercise after adjuvant treatment (based on the CHALLENGE trial) and an updated adjuvant treatment algorithm for stages 2 and 3 (ESMO Open 2026). The results of the ATOMIC trial (atezolizumab + FOLFOX in stage 3 dMMR, NEJM 2026) were published after this guideline and are not covered by it.
Limitations
This is the 2020 version and does not fully cover newer data (ctDNA, adjuvant immunotherapy in dMMR tumours, structured exercise); for updates, the ESMO guidelines website and the 2026 Express Update should be consulted.
This summary was prepared by the editorial team from the published paper; the original paper is the final reference. Read the original abstract on PubMed.